ZERO GRACE/ZERO MALICE

Amazon's purchase of One Medical could speed up American healthcare

The U.S. healthcare industry is a 7-ton seal bleeding at sea. Predators are circling. Unearned margin: price increases relative to inflation without quality improvements. Amazon is the 11-foot megalodon with 7-inch teeth. Amazon is no longer circling... but attacking.

In 2020 dollars, per capita U.S. healthcare spending increased from $2,968 in 1980 to $12,531. The result is a massive industry with 13% of the nation's workers and a fifth of GDP.

Doctor No

In 40 years, healthcare has made progress. From 73.7 in 1980 to 78.8 in 2019, life expectancy rose (before Covid knocked it back down a bit). Pharmacological therapies have revolutionized, and genetic research is paying off. The financial return, improvement split by cost increases, is terrible. No country has expense rises like the U.S., and no one spends as much per capita as we do. Developed countries have longer life expectancies, healthier populations, and less economic hardship.

Two-thirds of U.S. personal bankruptcies are due to medical expenses and/or missed work. Mom or Dad getting cancer could bankrupt many middle-class American families. 40% of American adults delayed or skipped needed care due to cost. Every healthcare improvement seems to have a downside. Same pharmacological revolution that helped millions caused opioid epidemic. Our results are poor in many areas: The U.S. has a high infant mortality rate.

Healthcare is the second-worst retail industry in the country. Gas stations are #1. Imagine walking into a Best Buy to buy a TV and a Blue Shirt associate requests you fill out the same 14 pages of paperwork you filled out yesterday. Then you wait in a crowded room until they call you, 20 minutes after the scheduled appointment you were asked to arrive early for, to see the one person in the store who can talk to you about TVs, who has 10 minutes for you. The average emergency room wait time in New York is 6 hours and 10 minutes.

If it's bad for the customer, it's worse for the business. Physicians spend 27% of their time helping patients; 49% on EHRs. Documentation, order entry, billing, and inbox management. Spend a decade getting an M.D., then become a bureaucrat.

No industry better illustrates scale diseconomies. If we got the same return on healthcare spending as other countries, we'd all live to 100. We could spend less, live longer and healthier, and pay off the national debt in 15 years. U.S. healthcare is the worst ever.

What now? Competition is at the heart of capitalism, the worst system of its kind.

Priority Time

Amazon is buying One Medical for $3.9 billion. I think this deal will liberate society. Two years in, I think One Medical is great. When I got Covid, I pressed the One Medical symbol on my phone; a nurse practitioner prescribed Paxlovid and told me which pharmacies had it in stock.

Amazon enables the company's vision. One Medical's stock is down to $10 from $40 at the start of 2021. Last year, it lost $250 million and needs cash (Amazon has $60 billion). ONEM must grow. The service has 736,000 members. Half of U.S. households have Amazon Prime. Finally, delivery. One Medical is a digital health/physical office hybrid, but you must pick up medication at the pharmacy. Upgrade your Paxlovid delivery time after a remote consultation. Amazon's core competency means it'll happen. Healthcare speed and convenience will feel alien.

It's been a long, winding road to disruption. Amazon, JPMorgan, and Berkshire Hathaway formed Haven four years ago to provide better healthcare for their 1.5 million employees. It rocked healthcare stocks the morning of the press release, but folded in 2021.

Amazon Care is an employee-focused service. Home-delivered virtual health services and nurses. It's doing well, expanding nationwide, and providing healthcare for other companies. Hilton is Amazon Care's biggest customer. The acquisition of One Medical will bring 66 million Prime households capital, domain expertise, and billing infrastructure. Imagine:

"Alexa, I'm hot and my back hurts."

"Connecting you to a Prime doctor now."

Want to vs. Have to

I predicted Amazon entering healthcare years ago. Why? For the same reason Apple is getting into auto. Amazon's P/E is 56, double Walmart's. The corporation must add $250 billion in revenue over the next five years to retain its share price. White-label clothes or smart home products won't generate as much revenue. It must enter a huge market without scale, operational competence, and data skills.

Current Situation

Healthcare reform benefits both consumers and investors. In 2015, healthcare services had S&P 500-average multiples. The market is losing faith in public healthcare businesses' growth. Healthcare services have lower EV/EBITDA multiples than the S&P 500.

Amazon isn't the only prey-hunter. Walmart and Alibaba are starting pharmacies. Uber is developing medical transportation. Private markets invested $29 billion in telehealth last year, up 95% from 2020.

The pandemic accelerated telehealth, the immediate unlock. After the first positive Covid case in the U.S., services that had to be delivered in person shifted to Zoom... We lived. We grew. Video house calls continued after in-person visits were allowed. McKinsey estimates telehealth visits are 38 times pre-pandemic levels. Doctors adopted the technology, regulators loosened restrictions, and patients saved time. We're far from remote surgery, but many patient visits are unnecessary. A study of 40 million patients during lockdown found that for chronic disease patients, online visits didn't affect outcomes. This method of care will only improve.

Amazon's disruption will be significant and will inspire a flood of capital, startups, and consumer brands. Mark Cuban launched a pharmacy that eliminates middlemen in January. Outcome? A 90-day supply of acid-reflux medication costs $17. Medicare could have saved $3.6 billion by buying generic drugs from Cuban's pharmacy. Other apex predators will look at different limbs of the carcass for food. Nike could enter healthcare via orthopedics, acupuncture, and chiropractic. LVMH, L'Oréal, and Estée Lauder may launch global plastic surgery brands. Hilton and Four Seasons may open hospitals. Lennar and Pulte could build "Active Living" communities that Nana would leave feet first, avoiding the expense and tragedy of dying among strangers.

Risks

Privacy matters: HIV status is different from credit card and billing address. Most customers (60%) feel fine sharing personal health data via virtual technologies, though. Unavoidable. 85% of doctors believe data-sharing and interoperability will become the norm. Amazon is the most trusted tech company for handling personal data. Not Meta: Amazon.

What about antitrust, then?

Amazon should be required to spin off AWS and/or Amazon Fulfillment and banned from promoting its own products. It should be allowed to acquire hospitals. One Medical's $3.9 billion acquisition is a drop in the bucket compared to UnitedHealth's $498 billion market valuation.

Antitrust enforcement shouldn't assume some people/firms are good/bad. It should recognize that competition is good and focus on making markets more competitive in each deal. The FTC should force asset divestitures in e-commerce, digital marketing, and social media. These companies can also promote competition in a social ill.

U.S. healthcare makes us fat, depressed, and broke. Competition has produced massive value and prosperity across most of our economy.

Dear Amazon … bring it.

Old power paradigm blocks new planetary paradigm

The difference between our reality and the media's reality is like a tale of two worlds. The greatest and worst of times, really.

Expanding information demands complex skills and understanding to separate important information from ignorance and crap. And that's just the start of determining the source's aim.

Trust who? We see people trust liars in public and then be destroyed by their decisions. Mistakes may be devastating.

Many give up and don't trust anyone. Reality is a choice, though. Same risks.

We must separate our needs and wants from reality. Needs and wants have rules. Greed and selfishness create an unlivable planet.

Culturally, we know this, but we ignore it as foolish. Selfish and greedy people obtain what they want, while others suffer.

We invade, plunder, rape, and burn. We establish civilizations by institutionalizing an exploitable underclass and denying its existence. These cultural lies promote greed and selfishness despite their destructiveness.

Controlling parts of society institutionalize these lies as fact. Many of each age are willing to gamble on greed because they were taught to see greed and selfishness as principles justified by prosperity.

Our cultural understanding recognizes the long-term benefits of collaboration and sharing. This older understanding generates an increasing tension between greedy people and those who see its planetary effects.

Survival requires distinguishing between global and regional realities. Simple, yet many can't do it. This is the first time human greed has had a global impact.

In the past, conflict stories focused on regional winners and losers. Losers lose, winners win, etc. Powerful people see potential decades of nuclear devastation as local, overblown, and not personally dangerous.

Mutually Assured Destruction (MAD) was a human choice that required people to acquiesce to irrational devastation. This prevented nuclear destruction. Most would refuse.

A dangerous “solution” relies on nuclear trigger-pullers not acting irrationally. Since then, we've collected case studies of sane people performing crazy things in experiments. We've been lucky, but the climate apocalypse could be different.

Climate disaster requires only continuing current behavior. These actions already cause global harm, but that's not a threat. These activities must be viewed differently.

Once grasped, denying planetary facts is hard to accept. Deniers can't think beyond regional power. Seeing planet-scale is unusual.

Decades of indoctrination defining any planetary perspective as un-American implies communal planetary assets are for plundering. The old paradigm limits any other view.

In the same way, the new paradigm sees the old regional power paradigm as a threat to planetary civilization and lifeforms. Insane!

While MAD relied on leaders not acting stupidly to trigger a nuclear holocaust, the delayed climatic holocaust needs correcting centuries of lunacy. We must stop allowing craziness in global leadership.

Nothing in our acknowledged past provides a paradigm for such. Only primitive people have failed to reach our level of sophistication.

Before European colonization, certain North American cultures built sophisticated regional nations but abandoned them owing to authoritarian cruelty and destruction. They were overrun by societies that saw no wrong in perpetual exploitation. David Graeber's The Dawn of Everything is an example of historical rediscovery, which is now crucial.

From the new paradigm's perspective, the old paradigm is irrational, yet it's too easy to see those in it as ignorant or malicious, if not both. These people are both, but the collapsing paradigm they promote is older or more ingrained than we think.

We can't shift that paradigm's view of a dead world. We must eliminate this mindset from our nations' leadership. No other way will preserve the earth.

Change is occurring. As always with tremendous transition, younger people are building the new paradigm.

The old paradigm's disintegration is insane. The ability to detect errors and abandon their sources is more important than age. This is gaining recognition.

The breakdown of the previous paradigm is not due to senile leadership, but to systemic problems that the current, conservative leadership cannot recognize.

Stop following the old paradigm.

Effective date: August 31, 2022

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And tips for anyone trying.

We see the same story every few years.

BREAKING NEWS: [Platform X] launched a social network. With Facebook's reputation down, the new startup bets millions will switch.

Despite the excitement surrounding each new platform (Diaspora, Ello, Path, MeWe, Minds, Vero, etc.), no major exodus occurred.

Snapchat and TikTok attracted teens with fresh experiences (ephemeral messaging and rapid-fire videos). These features aren't Facebook, even if Facebook replicated them.

Facebook's core is simple: you publish items (typically text/images) and your friends (generally people you know IRL) can discuss them.

It's cool. Sometimes I don't want to, but sh*t. I like it.

Because, well, I like many folks I've met. I enjoy keeping in touch with them and their banter.

I dislike Facebook's corporation. I've been cautiously optimistic whenever a Facebook-killer surfaced.

None succeeded.

Why? Two causes, I think:

People couldn't switch quickly enough, which is reason #1

Your buddies make a social network social.

Facebook started in self-contained communities (college campuses) then grew outward. But a new platform can't.

If we're expected to leave Facebook, we want to know that most of our friends will too.

Most Facebook-killers had bottlenecks. You have to waitlist or jump through hoops (e.g. setting up a server).

Same outcome. Upload. Chirp.

After a week or two of silence, individuals returned to Facebook.

Reason #2: The fundamental experience was different.

Even when many of our friends joined in the first few weeks, it wasn't the same.

There were missing features or a different UX.

Want to reply with a meme? No photos in comments yet. (Trying!)

Want to tag a friend? Nope, sorry. 2019!

Want your friends to see your post? You must post to all your friends' servers. Good luck!

It's difficult to introduce a platform with 100% of the same features as one that's been there for 20 years, yet customers want a core experience.

If you can't, they'll depart.

The causes that led to the causes

Having worked on software teams for 14+ years, I'm not surprised by these challenges. They are a natural development of a few tech sector meta-problems:

Lean startup methodology

Silicon Valley worships lean startup. It's a way of developing software that involves testing a stripped-down version with a limited number of people before selecting what to build.

Billion people use Facebook's functions. They aren't tested. It must work right away*

*This may seem weird to software people, but it's how non-software works! You can't sell a car without wheels.

2. Creativity

Startup entrepreneurs build new things, not copies. I understand. Reinventing the wheel is boring.

We know what works. Different experiences raise adoption friction. Once millions have transferred, more features (and a friendlier UX) can be implemented.

3. Cost scaling

True. Building a product that can sustain hundreds of millions of users in weeks is expensive and complex.

Your lifeboats must have the same capacity as the ship you're evacuating. It's required.

4. Pure ideologies

People who work on Facebook-alternatives are (understandably) critical of Facebook.

They build an open-source, fully-distributed, data-portable, interface-customizable, offline-capable, censorship-proof platform.

Prioritizing these aims can prevent replicating the straightforward experience users expect. Github, not Facebook, is for techies only.

What about the business plan, though?

Facebook-killer attempts have followed three models.

1. Utilize VC funding to increase your user base, then monetize them later. (If you do this, you won't kill Facebook; instead, Facebook will become you.)

2. Users must pay to utilize it. (This causes a huge bottleneck and slows the required quick expansion, preventing it from seeming like a true social network.)

3. Make it a volunteer-run, open-source endeavor that is free. (This typically denotes that something is cumbersome, difficult to operate, and is only for techies.)

Wikipedia is a fourth way.

Wikipedia is one of the most popular websites and a charity. No ads. Donations support them.

A Facebook-killer managed by a good team may gather millions (from affluent contributors and the crowd) for their initial phase of development. Then it might sustain on regular donations, ethical transactions (e.g. fees on commerce, business sites, etc.), and government grants/subsidies (since it would essentially be a public utility).

When you're not aiming to make investors rich, it's remarkable how little money you need.

If you want to build a Facebook competitor, follow these tips:

1. Drop the lean startup philosophy. Wait until you have a finished product before launching. Build it, thoroughly test it for bugs, and then release it.

2. Delay innovating. Wait till millions of people have switched before introducing your great new features. Make it nearly identical for now.

3. Spend money climbing. Make sure that guests can arrive as soon as they are invited. Never keep them waiting. Make things easy for them.

4. Make it accessible to all. Even if doing so renders it less philosophically pure, it shouldn't require technical expertise to utilize.

5. Constitute a nonprofit. Additionally, develop community ownership structures. Profit maximization is not the only strategy for preserving valued assets.

Last thoughts

Nobody has killed Facebook, but Facebook is killing itself.

The startup is burying the newsfeed to become a TikTok clone. Meta itself seems to be ditching the platform for the metaverse.

I wish I was happy, but I'm not. I miss (understandably) removed friends' postings and remarks. It could be a ghost town in a few years. My dance moves aren't TikTok-worthy.

Who will lead? It's time to develop a social network for the people.

Greetings if you're working on it. I'm not a company founder, but I like to help hard-working folks.

A J.Crew collaboration for fashion label Eveliina Vintage is not a paradox; it is a solution.

Eveliina Vintage's capsule collection debuted yesterday at J.Crew. This J.Crew partnership stopped me in my tracks.

Eveliina Vintage sells vintage goods. Eeva Musacchia founded the shop in Finland in the 1970s. It's recognized for its one-of-a-kind slip dresses from the 1930s and 1940s.

I wondered why a vintage brand would partner with a mass shop. Fast fashion against vintage shopping? Will Eveliina Vintages customers be turned off?

But Eveliina Vintages customers don't care about sustainability. They want Eveliina's Instagram look. Eveliina Vintage collaborated with J.Crew to give customers what they wanted: more Eveliina at a lower price.

Vintage: A Fashion Option That Is Eco-Conscious

Secondhand shopping is a trendy response to quick fashion. J.Crew releases hundreds of styles annually. Waste and environmental damage have been criticized. A pair of jeans requires 1,800 gallons of water. J.Crew's limited-time deals promote more purchases. J.Crew items are likely among those Americans wear 7 times before discarding.

Consumers and designers have emphasized sustainability in recent years. Stella McCartney and Eileen Fisher are popular eco-friendly brands. They've also flocked to ThredUp and similar sites.

Gap, Levis, and Allbirds have listened to consumer requests. They promote recycling, ethical sourcing, and secondhand shopping.

Secondhand shoppers feel good about reusing and recycling clothing that might have ended up in a landfill.

Eco-conscious fashionistas shop vintage. These shoppers enjoy the thrill of the hunt (that limited-edition Chanel bag!) and showing off a unique piece (nobody will have my look!). They also reduce their environmental impact.

Is Eveliina Vintage capitalizing on an aesthetic or is it a sustainable brand?

Eveliina Vintage emphasizes environmental responsibility. Vogue's Amanda Musacchia emphasized sustainability. Amanda, founder Eeva's daughter, is a company leader.

But Eveliina's press message doesn't address sustainability, unlike Instagram. Scarcity and fame rule.

Eveliina Vintages Instagram has see-through dresses and lace-trimmed slip dresses. Celebrities and influencers are often photographed in Eveliina's apparel, which has 53,000+ followers. Vogue appreciates Eveliina's style. Multiple publications discuss Alexa Chung's Eveliina dress.

Eveliina Vintage markets its one-of-a-kind goods. It teases future content, encouraging visitors to return. Scarcity drives demand and raises clothing prices. One dress is $1,600+, but most are $500-$1,000.

The catch: Eveliina can't monetize its expanding popularity due to exorbitant prices and limited quantity. Why?

1. Most people struggle to pay for their clothing. But Eveliina Vintage lacks those more affordable entry-level products, in contrast to other luxury labels that sell accessories or perfume.

2. Many people have trouble fitting into their clothing. The bodies of most women in the past were different from those for which vintage clothing was designed. Each Eveliina dress's specific measurements are mentioned alongside it. Be careful, you can fall in love with an ill-fitting dress.

3. No matter how many people can afford it and fit into it, there is only one item to sell. To get the item before someone else does, those people must be on the Eveliina Vintage website as soon as it becomes available.

A Way for Eveliina Vintage to Make Money (and Expand) with J.Crew Its following

Eveliina Vintages' cooperation with J.Crew makes commercial sense.

This partnership spreads Eveliina's style. Slightly better pricing The $390 outfits have multicolored slips and gauzy cotton gowns. Sizes range from 00 to 24, which is wider than vintage racks.

Eveliina Vintage customers like the combination. Excited comments flood the brand's Instagram launch post. Nobody is mocking the 50-year-old vintage brand's fast-fashion partnership.

Vintage may be a sustainable fashion trend, but that's not why Eveliina's clients love the brand. They only care about the old look.

And that is a tale as old as fashion.